Nutrition in aki
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Nutrition in AKI. Norma J Maxvold MD Associate Professor of Pediatrics Pediatric Critical Care Medicine Children’s Hospital of Richmond Virginia Commonwealth University. Nutrition In AKI. Objectives: Overview Nutritional Needs in Children with AKI

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Nutrition in aki

Nutrition in AKI

Norma J Maxvold MD

Associate Professor of Pediatrics

Pediatric Critical Care Medicine

Children’s Hospital of Richmond

Virginia Commonwealth University


Nutrition in aki1

Nutrition In AKI

Objectives:

  • Overview Nutritional Needs in Children with AKI

  • Effect of renal support on Nutrition

  • Diagram of Nutrition Prescription during AKI


Nutrition in aki2

Nutrition in AKI

CATABOLIC, HYPERMETABOLIC STATE

Malnutrition

AKI

Acidosis,

Uremia,

Impaired AA Conversion, iLipid Oxidation

Acute Illness: Stress Response

hCytokines, Hormonal changes,

Altered Substrate Utilization

Malnutrition


Energy expenditure

Energy Expenditure

  • Decreased physical activity, decreased insensible losses, and transient absence of growth during the acute illness may reduce energy expenditure

  • Pediatric patients may not exhibit significant hypermetabolism post-injury?

Mehta, N. and Duggan, C. (2009); Mehta, N. et al. (2009); Hardy Framson et al. (2007); Vasquez Martinez et al. (2004); Hardy et al. (2002); Briassoulis et al. (2000); Letton et al. (1995), Agus and Jaksic (2002)


Nutrition in aki

  • Substrate Utilization/Nutrient Composition

    75%CHO:15% AA: 10% Lipid

    15%CHO: 15%AA: 70% Lipid

    C13 Glucose, C13 Acetate

    Maximum Glu Oxidation 4mg/kg/min

    Lipogenesis from Excess Glucose Metabolism

    Gluconeogenesis and Protein Catabolism was not effected

    [Tappy et al. Crit Care Med 1998;26:860-867]


Hypermetabolism in children with critical illness

Hypermetabolism in Children with Critical Illness

AveEnergy Intake REE

Coss-Bu( Am J Clin Nutr 2001)0.23 MJ/kg/d>25%

Verhoeven(Int Care Med 1998) 0.24 MJ/kg/d >14%

Joosten (Nutrition 1999) 0.26 MJ/kg/d >20%


Comparison of mee vs cree

Comparison of MEE vs. cREE

Briassoulis et al. (2000)


Indirect calorimetry and crrt

Indirect calorimetry AND CRRT

  • IC: measure resting energy expenditure.

  • Based on: Expired CO2 and O2 (O2 consumption + CO2 production).

    Potential problem with CRRT

May affect IC

measurements.

IC may not be

reliable?

HCO3/CO2 fluxes

Hemofilter

Effluent

Dialysis fluid


Nutrition in aki3

Nutrition in AKI

Energy and Substrate Use in Acute Illness in Children Coss-Bu et al Am J ClinNutr2001;74:664

Normal Metabolic : Hypermetabolic

mREE 0.16 mREE 0.28

Fat Oxidation -22mg/min Fat Oxidation 27mg/min

np RQ 1.21 npRQ 0.86

Energy Intake: 0.25MJ/kg/d [55kcal/kg/d]

CHO: 10 g/kg/d ; Fat: 1.4g/kg/d;

Protein:2.1g/kg/d


Nutrition in aki4

Nutrition in AKI

No Growth occurs during Acute Illness

Focus : Prevent Malnutrition

Children at Risk:

High basal rate of metabolism

Limited reserves

Baseline poor nutrition

+

Uremia and acidosis

Altered renal Amino Acid metabolism, lipid metabolism,

Fluid and Solute Clearance,

+

hLosses for Renal Replacement Therapy


Protein turnover in renal disease

Protein Turnover in Renal Disease

UNA/ PCR in Acute Kidney Injury

  • Adult Studies:

  • Protein Catabolic Rate ~ 1.4 - 1.7 g/kg/d

    [Macias WL, et al. JPEN 1996;20:56-62]

    [Chima CS, et al. JASN 1993; 3:1516-1521]

    Pediatric Studies: Urea Nitrogen Appearance

    UNA ~ 185- 290mg/kg/d (PCR 1.1- 1.8 g/kg/d)

    [ Kuttnig M, et al. Child NephrolUrol 1991;11:74-78]

    [ Maxvold N, et al. Crit Care Med 2000;28:1161-1165]


Nutrition in aki5

Nutrition in AKI

Caloric Support:

Protein Support:

Adult:

npkcal 25kcal/kg/d

CHO 5 g/kg/d

Fat 0.8-1.2g/kg/d

Pediatric:

Npkcal 40-65kcal/kg/d

Adult:

Protein 1.5-2.0 g/kg/d

Pediatric:

Protein 2.0-3.0 g/kg/d

( Cano N et al ClinNutr 2006 and 2008)


Nutrition and pcrrt

Nutrition and PCRRT

Can Nitrogen Balance be Achieved

in AKI patients on CRRT?

Conflicting Studies

Bellomo et al Ren Fail 1997

Protein Intake : Nitrogen Balance

1.2 g/kg/d AA -5.5 g N /d

2.5 g/kg/d AA -1.9 g N /d


Does increasing protein intake help

Does increasing protein intake help?

  • Scheinkestel et al.

    1. Nutrition, 2003

    In 11 critically ill adults on CRRT, protein intake 2.5 g/kg/day led to a) normal amino acid levels and b) positive nitrogen balance.

    2. Nutrition, 2003

    50 critically ill adults on CRRT: 1.5 vs 2.0 vs 2.5 g/kg/day.

    NB related to protein intake.

    NB related to hospital stay

    Protein intake 2.5 g/kg/d: improved survival!

Potential for losses during CRRT


Glutamine supplementation

Glutamine Supplementation

[Ziegler et al, Ann Intern Med 1992;116:821]

45 BMT patients with Parenteral Glutamine (L-Gln) Supplemention : 0.57g/kg/d Gln &2.07g/kg/d AA Intake

Improved Nitrogen Balance: -1.4g/d vs -4.2g/d

i Clinical infections: 3/24 vs 9/21

  • Hospital stay: 29 days vs 36 days

    [ Schloerb et al; JPEN 1993; 17:407-413]

  • Hospital stay: 26 days vs 32 days

  • Total Body Water: -1.2 L vs 2.2 L (Bioimpedance)


Nutrition and pcrrt1

Nutrition and PCRRT

Lipid Metabolism

 Fatty Acid Utilization during acute illness

Mitochondrial adaptation to acute stress

(Carnitine dependent enzymes)

Calvani et al Basic Res Cardiol 2000

Mitochondrial control of FFA oxidation and CHO oxidation

AcetylCoA/ CoA ratio on PDH Complex


Smoflipid iv emulsion

SMOFlipid IV Emulsion

Advantages:

  • Lower Linoleic concentration

  • MCT rapidly cleared from plasma

  • Olive oil less prone to peroxidation

  • Fish oil beneficial anti-inflammatory

    Early Studies : Good Safety profile

    ClinNutr 2013;32:224

    JPEN 2012; 36:81S


Potential for losses during crrt

Potential for losses during CRRT

Water Soluble Vitamins

  • Vit B1 Def Altered Energy Metabolism,

    h Lactic Acid, Tubular damage

  • Vit B6Def Altered Amino acid and lipid

    metabolism

  • FolateDef Anemia

  • Vit C Def Limit 200 mg/d as precursor to

    Oxalic acid


Nutrition in children with aki

Nutrition in Children with AKI


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